NHS in England Closed After Initial Enquiries Search on PHSO website

Royal Free London NHS Foundation Trust

P-004972 · Statement · Decision date: 3 March 2026 · View Royal Free London NHS Foundation Trust scorecard
Administration
Complaint (AI summary)
Mr A complained the Trust did not action a referral for an ultrasound-guided aspiration and steroid injection in his knee, causing pain, distress, and the need for emergency surgery in Bulgaria.
Outcome (AI summary)
The complaint was closed. While there was a delay with the referral, the Ombudsman could not link this to Mr A needing to pay for treatment in Bulgaria.

Full decision details

The Complaint

4.Mr A complains about the actions of Royal Free London NHS Foundation Trust (the Trust) during November 2021 – August 2022. Specifically, he says the Trust did not action a referral request for an ultrasound guided aspiration and steroid injection in his knee.

5.Mr A tells us the delay with his treatment caused him severe pain and distress. He explained he could not walk or sleep properly and had to take time off work. Mr A added he had to pay for emergency surgery in Bulgaria after the cyst in his knee swelled significantly.

6.Mr A is seeking £1,900 to cover the cost of his emergency surgery.

Background

7.Mr A’s GP referred him to the Trust’s Specialist Care Assessment Service (SCAS) in September 2021 with a one-month history of knee pain.

8.An Advanced Physiotherapy Practitioner (APP) saw Mr A in November 2021. The APP assessed Mr A’s left knee and referred him for an MRI scan.

9.Mr A’s MRI scan showed a partial tear of the anterior cruciate ligament and confirmed Mr A had a ganglion cyst. Mr A told the Trust he had already had a lot of physiotherapy and wanted to know whether he could have any surgery to remove the cyst.

10.The APP contacted Mr A in December 2021 after speaking with a consultant, who advised that there was a 30% chance of reoccurrence if the ganglion cyst was surgically removed. The APP referred Mr A for a left knee ultrasound guided aspiration and a steroid injection and discharged him from the SCAS. The APP informed Mr A the maximum wait time for the appointment would be four months.

11.After four months, Mr A chased the Trust for information on his appointment and was told he was on the waiting list. He contacted the SCAS again in June 2022. The Trust realised at this point that the initial referral had been mislaid and scheduled an appointment for Mr A for August 2022.

12.In early August 2022, Mr A booked a trip to visit family in Bulgaria. He says that during this trip he attended the emergency department due to the pain in his knee. He had an MRI scan and was diagnosed with synovitis, plica syndrome and a baker’s cyst. Mr A paid £1,900 for an arthroscopy procedure. Mr A cancelled his scheduled appointment with the Trust following this procedure.

Findings

16.Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done this, we cannot link the events complained about with the negative impact Mr A has claimed.

17.Mr A is unhappy that the Trust misplaced his referral for an ultrasound guided aspiration and a steroid injection in his knee. He explained that in December 2021, the Trust told him the maximum wait time on the referral was four months.

18.Mr A explained that when he was chasing the Trust for an update, he was told he was still on the waiting list. Mr A tells us that in June 2022, the Trust told him his referral had been misplaced and scheduled an appointment for him in August 2022. Mr A says that during the time he was waiting for his appointment, he was in significant pain and whilst on a family visit in Bulgaria, he had to pay for emergency surgery on his knee.

19.We are very sorry to hear how these events impacted Mr A and acknowledge the pain he was in whilst waiting for his appointment at the Trust.

20.In its complaint response, the Trust acknowledged that the referral made in December 2021 was misplaced in its system and apologised to Mr A for any inconvenience this caused him.

21.The relevant NHS guidance on waiting times says:

‘The maximum waiting time for non-urgent, consultant-led treatments is 18 weeks from the day your appointment is booked through the NHS e-Referral Service, or when the hospital or service receives your referral letter.’

22.Mr A was given a scheduled appointment for 26 August 2022, which is approximately 34 weeks after the referral was requested in December 2021. Guidance suggests that Mr A should have been waiting no more than 18 weeks for an appointment, which means he should have been given appointment no later than 5 May 2022. This is a delay of approximately 16 weeks. We are sorry that this happened, and we consider this 16-week delay could have been avoided if the referral was not misplaced in the Trust’s system.

23.Mr A says that whilst he was in Bulgaria at the start of August 2022, he attended the hospital due to symptoms with his knee. He explained that this visit was not planned, and he had to undergo emergency surgery on his knee which he paid around £1,900 for. Mr A feels this could have been avoided if there were no unnecessary delays with his appointment at the Trust. Following his surgery in Bulgaria, Mr A contacted the Trust and cancelled the appointment scheduled for August 2022 as it was no longer required.

24.The records from the clinic in Bulgaria state that following an MRI scan, Mr A was diagnosed with synovitis, plica syndrome and a baker’s cyst. The records show a recommendation of surgical treatment (urgent arthroscopic surgery) given the condition of Mr A’s knee joint.

25.We understand the key motivation for Mr A bringing his complaint to us is to recover the £1,900 he paid for his procedure in Bulgaria.

26.Our adviser explained that the diagnoses Mr A received in Bulgaria (synovitis, plica syndrome and a baker’s cyst) do not normally require any urgent surgery. Our adviser said that surgery can be considered in refractory cases which do not respond to physiotherapy or injection treatment. Given that the surgery in Bulgaria happened prior to the scheduled appointment at the Trust, we cannot know whether the intended injection treatment at the Trust would have been effective or not.

27.Our adviser said that the delay with treatment at the Trust may have led to increased pain and swelling in Mr A’s knee, however urgent surgery would not be generally needed for his symptoms and treatment with analgesia or injection could have been considered.

28.Based on the evidence we have received, we do not consider we are able to link the delay with the referral at the Trust to Mr A paying for emergency surgery in Bulgaria. We do however acknowledge the delay was unacceptable and we are sorry that this happened. The delay with the referral and subsequent appointment offered to Mr A clearly falls outside of what is expected in the relevant NHS guidance.

29.Our principles for remedy say:

‘There are no automatic or routine remedies for injustice or hardship resulting from maladministration or poor service. Remedies may be financial or non-financial.

An appropriate range of remedies will include:

• an apology, explanation, and acknowledgement of responsibility

• remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these • financial compensation for direct or indirect financial loss, loss of opportunity, inconvenience, distress, or any combination of these.

30.In its complaint response, the Trust acknowledged it had misplaced the referral and apologised to Mr A for this. It also said that it has taken steps to improve its service to prevent the same things happening again. The Trust explained that it has implemented a new system where additional clerical staff are copied into referral requests which will ensure better tracking and management of appointments.

31.The Trust has acknowledged responsibility for the delay, apologised and taken steps to improve its service as a result of Mr A’s complaint. We do consider these actions to be appropriate and in line with our principles for remedy. These actions are a direct result of Mr A making a complaint; therefore we thank him for raising his concerns.

32.In summary, we are very sorry to learn of the delays with Mr A’s appointment at the Trust. We have considered all the evidence and conclude that we are unable to link the delay with Mr A’s appointment and him paying £1,900 for surgery in Bulgaria, given the diagnoses he received do not normally require urgent surgery. Additionally, government guidance for travel to Bulgaria advises people to have appropriate insurance before travelling. If Mr A had this in place, it is likely this would have covered any necessary, urgent surgery. For these reasons, we shall not consider this complaint further. We thank Mr A for taking the time to make his complaint as this has directly led to the Trust implementing service improvements. We acknowledge our decision may be disappointing to Mr A and we apologise if this causes him any upset or distress.

Our Decision

1. We have carefully considered Mr A’s complaint about Royal Free London NHS Foundation Trust. We are sorry to learn of the events which led Mr A to make a complaint, and we acknowledge the difficult experience he went through with his knee. We understand the importance of his complaint.

2.We have looked at what Mr A told us and evidence we received from the Trust. We have investigated Mr A’s complaint regarding the Trust’s delay with a referral for a steroid injection and an ultrasound guided aspiration in his knee. We have decided we cannot link the events complained about to Mr A paying for treatment in Bulgaria.

3.We hope this statement helps Mr A understand how we reached our decision.

Other Decisions About Royal Free London NHS Foundation Trust

P-005020 · 11 Mar 2026
Mr L complains that in May 2024 the Trust did not provide the right ear plugs for an MRI scan. …
Closed After Initial Enquiries
P-004644 · 20 Jan 2026
Miss A complains about how Moorfields Eye Hospital NHS Foundation Trust transferred her care from its oncology department to Royal …
Partly Upheld
P-004320 · 24 Nov 2025
Mr F complains that the Trust rejected the referral it received for him to have revision of his private cosmetic …
Closed After Initial Enquiries
P-004153 · 20 Oct 2025
Mrs B complains about the Trust’s management of her mother’s abdominal pain in July 2023.
Partly Upheld
P-004015 · 28 Sep 2025
Ms X complains about the care and treatment provided to her husband by an NHS Trust.
Partly Upheld
View all decisions for this organisation →